You may be eligible for savings options that include a $0 co-pay. Plus, you can enroll in the LEQVIO® Care Program, which offers personalized guidance to help you stay on track with your treatment.
I would like to receive the $0 co-pay card, and confirm that I have read the Terms and Conditions and that the following is true:
I would like to enroll in phone support from the LEQVIO Care Program—an optional program to help you stay on track with your treatment plan, including your own dedicated Care Specialist to provide medication reminders, healthy living tips and tools.
By checking the box, I agree to receive calls and texts at the phone number provided. I understand calls and texts may be autodialed or prerecorded and are not a condition of purchase. Message and data rates may apply. Text STOP to opt out and HELP for help.
I am electronically signing this document, and the check mark has the same effect as a pen-and-paper signature or initial(s). I have also read and agree to the Novartis
Consent to Receive Electronic Disclosures.
I agree to also be registered in LEQVIO Care, where I will receive patient support and resources, including a personalized welcome kit, treatment education, and helpful tools.
By clicking “Submit,” I agree to the Novartis Pharmaceuticals Corporation
LEQVIO and the LEQVIO logo are registered trademarks of Novartis AG.
Copyright © 2021 Novartis Pharmaceuticals Corporation. All rights reserved.
All rights reserved.
I authorize my health care providers, pharmacies, health insurers, and their service providers (“Providers”) to disclose information relating to my insurance benefits, medical condition, treatment, and prescription details (“Personal Information”) to Novartis Pharmaceuticals Corporation, its affiliates and service providers (“Novartis”), and the Novartis Patient Assistance Foundation, Inc., and its service providers (“NPAF”), so they can provide the following support services (“Services”):
In delivering the Services, Novartis and NPAF may share my Personal Information with each other and with my Providers, or with government agencies or other financial assistance programs that might help me pay for my medication. They may combine information collected from me with information collected from other sources and use that information to administer the Services. My pharmacies or other health care providers may receive payment from Novartis or NPAF for providing certain Services, such as medication or refill reminders, based on my enrollment or participation. Once I authorize disclosure of my Personal Information, it may no longer be protected by federal health privacy law and applicable state laws.
I understand I do not have to sign this Authorization to get my medication or insurance coverage, that I have a right to a copy, and I can cancel this Authorization at any time by calling 1-844-267-3689 or writing to:
Human Care Systems Customer Interaction Center
84 State Street
Boston, MA 02109
Customer Interaction Center Novartis Pharmaceuticals Corporation
One Health Plaza
East Hanover, NJ 07936-1080
The Authorization will expire 5 years after I sign it, or earlier if required by state law, unless I cancel it sooner. If I cancel it, I may no longer qualify for Services from Novartis or NPAF, but it will not impact my Providers’ treatment or my insurance benefits. I also understand that if a Provider is disclosing my Personal Information to Novartis or NPAF on an authorized, ongoing basis, my cancellation will be effective with respect to that Provider as soon as they receive notice of my cancellation. Cancellation will not affect prior uses or disclosures.
I agree for myself and certify (if applicable) that my caregiver agrees to receive nonmarketing calls and texts from Novartis or NPAF, including through an autodialer or prerecorded voice, at the number(s) provided.
From time to time, Novartis Pharmaceuticals Corporation (“we,” “us,” “our,” or “Company”) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through your user account in various Novartis programs. Please read the information below carefully.
At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You may request delivery of such paper copies from us by following the procedure described below.
If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform us of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below.
If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in communications with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. To indicate to us that you are changing your mind, you must contact us as described below.
Unless you tell us otherwise in accordance with the procedures described herein, we will provide electronically to you all required notices, disclosures, authorizations, acknowledgments, and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given us. Thus, you can receive all the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below. Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us.
You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows:
To let us know of a change in your email address where we should send notices and disclosures electronically to you, you must call us at 1-888-NOW-NOVA (1-888-669-6682) and state: your previous email address, your new email address. We do not require any other information from you to change your email address.
To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you must call us at 1-888-NOW-NOVA (1-888-669-6682) and state your email address, full name, US postal address, and telephone number.
To inform us that you no longer want to receive future notices and disclosures in electronic format you may:
Windows 2000 or Windows XP
Internet Explorer 6.0 or above
Internet Explorer 6.0, Mozilla FireFox 1.0, NetScape 7.2 (or above)
Access to a valid email account
800 x 600 minimum
*These minimum requirements are subject to change. If these requirements change, we will provide you with an email message at the email address we have on file for you at that time, with the revised hardware and software requirements, at which time you will have the right to withdraw your consent.
To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please verify that you were able to read this electronic disclosure by checking the appropriate box on the enrollment page.
By checking the “I Agree” box on the enrollment page, you confirm that: